Wet & Healthy

The Health Benefits

of Aquatic Activity
Bruce E. Becker, MD
Clinical Professor, University of Washington School of Medicine
Research Professor, Washington State University
Director, National Aquatics & Sports Medicine Institute
beckerb@wsu.edu
Aquatic vs. Land Activity
! " Buoyancy creates unique opportunities!
! " Multidimensional movement is easy!
! " Viscosity adds graded resistance!
! " Immersion is usually pleasurable!
! " Relaxation is nearly automatic for most!
! " The water has its own healing
properties with unique physiologic
effects!
 Pressure Increases!
Neck depth = negligible!

Increasing Hydrostatic Force! Chest depth = ± 18 mmHg!

Waist depth = ± 36 mmHg!

Thigh depth = ±70 mmHg!

Ankle depth = ±110 mmHg!

 Cardiovascular Changes with Immersion
Thermoneutral water temperature, neck depth!
Changes during immersion in %!

Arborelius, Aerospace Med 43:701-707, 1978; Risch, Pflugers Arch, 374:119-120, 1978!
 Water Immersion to !
chest or higher!

Increased hydrostatic !
pressure!

Venous compression! Lymphatic compression!

Central blood!
volume increases!

Atrial pressure! Pulmonary Arterial ! Cardiac volume!

rises! Pressure rises! increases!

Stroke!
volume increases!

Cardiac output!
increases!
Vascular Pressures with Immersion

Epstein, Circ Res 39:619-628, 1976!

 Muscle Blood Flow with Immersion
Thermoneutral temperature, neck depth, seated!
Blood Flow in ml / min / 100 gm. tissue!

Nearly a 250% increase in

muscle blood flow!

Balldin, Aerospace Med 42:489-493, 1971!

Aquatic Therapy Effects on CHF
Neck depth immersion at 41° C (105.8° F)!

CT Ratio in %!

LV Dimension in mm!

in %!
Ejection Fraction

4 week therapy course!

Tei & Tanaka, J Cardiol 1996:27:29-30!

Warm Water Immersion in CHF

Cider A, Svealv BG, Tang MS, Eur J Heart Failure, 8:3, 308-313, 2006!
25 pts with CHF, 8 weeks training at 3 times per week!

Cider A, Schaufelberger M, Sunnerhagen KS, Andersson B, Eu J Heart Failure 5 (2003) 527-535!

 Renal Hormone Changes with Immersion
Changes in %!

2 !
PGE

Renin!
Aldosterone!
ADH!

Epstein, Murray; Renal effects of head out immersion in humans: a 15-year update; Physiological Reviews. 1992!
Renal Function Changes with Immersion

Study End!
Epstein, Physiol Rev 72:577, 1992!
 Aquatics & Bone Density!

! " In older male Masters swimmers,

increased bone density has been
found.!
! " In older female Masters swimmers, no
effect has been noted.!
! " In younger individuals, swimming did
not add bone mineral content as
effectively as weight-bearing exercise.!
Aquarobic Effect on BMD, Fitness &
Well-being @1 year!
77 females, ages 50-70, 1 hour/day, 3 days per week, 12 months!

0%!

Bravo, Gauthier et al, Arch PMR, 78, 1375-80,1997!

Osteoporosis and Aquatic Therapy!
! " The aquatic environment is a very
appropriate place to begin a
strengthening and endurance program!
! " The pool will probably not provide a
major bone-deposition stimulus, or
reverse loss of bone mineralization!
! " Transitioning to land-based impact
activities is the goal for osteoporosis!
 Respiratory Motor System:!
• Neck muscles, incl. Scalenes, SCM!
• Diaphragm!
• Intercostal muscles!
• Abdominal muscles!
Impairment seen in:!
•" Congestive Heart Failure!
•" Neuromuscular Disease!
•" Malnutrition & General Debilitation!
 Pulmonary Function Divisions!
Inspiratory Inspiratory Reserve Volume
Capacity

Vital Capacity
Tidal Volume

Expiratory Reserve Volume

Functional
Residual
Capacity
Residual Volume
 Energy Costs of Immersed Breathing
Neck depth immersion at thermoneutral temperature!

Total Work of Breathing

(kg-cm)!

Elastic Component!

Dynamic Component!

0! 5! 10! 15!

Work in Kg/cm.!
Hong, J Appl Physiol 27:535-538, 1969!
D ra m ati c i n c re a s e
in Hydrostatic Pressure!

wo r k of b re at h i n g
 Head-out Water Immersion!

Central blood volume! Chest wall pressure! Abdom. compression!

Pulmonary Vessel fill! Chest circumference! Diaphragm height!

Diffusion capacity! Airway resistance! Lung volume & VC!

Efficiency! PO2! Expiratory flow rate! Pulmonary compliance!

 Inspiratory Muscle Training
6 weeks of daily training!

! " Attenuates blood lactate formation !

! " Improves exercise recovery time in
repetitive sprint activity!
! " Improves perceptual response to
exertion!
! " Improves time trial performance,
especially in longer events (4 to 5%)!
Romer et al, Int j sports Med 23(5) 2002, MSSE 34(5) 2002!
NSPF / WSU Respiratory Study
! " 100 college students, 50 per group!
! " Group 1: Deep water exercise, 50 minutes/
session 3 times per week at RPE 15!
! " Group 2: Land aerobics, 50 minutes /
session 3 times per week at RPE 15!
!" Data points: prestudy, week 8 and week 15!
! " PImax, PImax-VL curves, PFTs!
! " % body fat via BodPod!
! " Treadmill VO2 max!
 Exercise Programming
! " Exercise sessions between groups were
designed to be similar in all aspects!
! " Warm-up, aerobic exercise, and cool-down
times were the same between groups!
! " Choreography was similar and in the same
order between groups!
! " Instructor supervision, motivation and
feedback was similar!
! " Students were instructed to maintain a
desired RPE of 15. An RPE of 15 is
considered “Hard”!
 Study Methods!
Initial Assessment!

! " All subjects were tested first for resting heart

rate and bp, then body fat percentage, followed
by spirometry, and then finally maximal oxygen
consumption.!
! " There was no difference between groups on
testing times.!
! " Subjects self selected their testing time for
peak performance.!
 Lung Measurements Assessed
! " Peak inspiratory pressure (PImax)!
! " Peak expiratory pressure (PEmax)!
! " Mean airway pressure (MAP)!
! " Mean inspiratory pressure (MIP)!
! " Tidal volume (Vt)!
! " Forced vital capacity (FVC)!
! " Maximal inspiratory flow (MIF)!
! " Maximal inspiratory minute volume (VIatph)!
! " Maximal expiratory minute volume (VEatph)!
! " Maximal expiratory flow (MEF)!
 Starting Group Comparisons!
Variable! Water! Land!
Age! 22.34! 21.04!
Gender M/F! 26/25! 30/20!
Active (#3 days/wk)! 68%! 62%!
% Body Fat! 24.25! 23.67!
Weight (Kg)! 79.85! 77.12!
BPsys! 122.8! 123.33!
BPdia! 67.82! 69.43!
HRrest! 90.43! 88.78!
VO2max! 42.17! 42.96!
Study Results between Groups!
Variable! Water! Land! Significance!

PImax! 183.39! 185.73! p=0.522!

PEmax! 194.83! 193.2! p=0.658!
MIP! 15.08! 15.68! p=0.802!
Vt! 2.73! 2.67! p=0.686!
FVC! 3.04! 2.90! p=0.468!
MIF! 89.46! 88.14! p=0.802!
MEF! 401.87! 396.31! p=0.812!
MAP! 14.71! 14.21! p=0.604!
 Max Expiratory Vital Capacity (FVC)!
Changes between groups across study interval!

Nonsignificant at p=0.468!
Liters!
 Max Inspiratory Vital Capacity (FIVC) !
Changes between groups across study interval!
Liters!

Statistically significant at p=0.042!

 Tidal Volume at Max Exercise!
Liters!

Statistical value p= 0.068!

 Study Results: Both Groups!
Variable! Week 0! Week 8! Week 15! Significance!
Body Weight! 77.16! 75.1! 75.41! 0.0001!
% Body Fat! 24.16! 22.47! 23.18! 0.0001!
VO2max! 42.03! 46.2! 45.82! 0.0001!
Vt! 1.3! 1.26! 1.05! 0.0001!
FVC! 2.97! 4.38! 4.36! 0.0001!
FIVC! 3.11! 4.34! 4.32! 0.0001!
PEF! 194.11**! 503.53! 511.37! 0.0001!
MIF!
VIatps! 88.81! 93.82! 90.29! 0.0001!
VEatps! 108.75! 117.16! 110.71! 0.0001!
MEF!
 Preliminary Study Results
! "The aquatic group showed improvement in
ventilatory capacity (FIVC) and respiratory
endurance (MVV12 sec) compared to the land
group.!
! "Both groups showed statistically significant
improvements in:!
! "Weight loss and lean body mass!
! "% body fat!
! "VO2max!
! "Resting tidal volume!
! "Peak expiratory flow pressures!
The Cocoon Effect!
 Probable Causes

! " Autonomic Nervous System downregulation!

! " Heart Rate Variability changes!
! " Catacholamine changes!
! " Blood Pressure changes!
! " EEG changes!
! " Muscle tone changes!
The WSU Research Questions:

1."What are the effects, potential health

benefits and risks of aquatic immersion
at various temperatures?!
2."What aquatic temperatures produce the
maximum positive effects??!
3."What is the time course of these
changes?!
 Our Lab
•" 3 Prodigy™ tubs, donated by Hot Spring Spas.!
–" Cool tub maintained at 88° F (31.1°C)!
–" Neutral maintained at 98° F (36.7°C)!
–" Warm tub maintained at 102° F (38.9°C)!
•" CorTemp! telemetry system!
•" BioPac! monitoring system!
–" ECG!
–" Blood flow measurement through laser doppler!
–" EEG!
–" Core temperature!
•" Blood pressure monitoring!
•" Body fat percentage (BodPod!)!
 Study Methodology
•" Subjects recruited, consent signed!
•" CoreTemp pill swallowed!
•" Subjects then connected to our
research hardware!
•" Sat at tubside for 6 minutes, immersed
in cool tub for 24 min, rest out for 12
minutes, neutral immersion for 24 min,
rest out for 12 min, warm tub for 24 min,
recovery for 12 min.!
 HRV & Health
•" Autonomic imbalance has been suggested to
be the final common pathway in many
diseases!
•" Highly correlated with cardiovascular health!
•" Associated with diabetes, inflammatory
processes, and immune dysfunction!
•" An increase in parasympathetic tone
decreases release of inflammatory cytokines,
& increased sympathetic tone increases them!
 HRV Analysis
•" Computerized breakdown into frequency
spectra via fast Fourier Transformation:!
–" Ultra-low frequency (<0.04 HZ) (respiratory)!
–" Very low frequency (0.04HZ) (sympathetic activity)!
–" Low frequency (0.04-0.15HZ)(sympathetic &GI)!
–" High frequency (0.15-0.4HZ) (parasympathetic
activity)!
–" Sympathetic!
–" Vagal (parasympathetic)!
–" Sympathetic / Vagal balance!
Core Temperature Response !
by Age Group!
Heart Rate Change during Immersion!
Blood Pressure Response !
by Age Group!
 700!
Older Group!
Younger
Group!
600!

500!
Blood Perfusion Units!

400!

300!

200!

100!

0!
Period 1!Period 2!Period 3! Period 1!Period 2!Period 3! Period 1!Period 2!Period 3!

Pre! Cool! Recovery! Neutral! Recovery! Warm! Recovery!

VLF Power Spectral Display by Age Group!
HF Power Spectral Display by Age Group!
Sympathovagal Balance by Age Group!
 Study Result Summary
•" There seems to be a very significant
effect of warm water immersion upon
the autonomic nervous system!
•" That effect seems to enhance the
balance between parasympathetic and
sympathetic components, and is likely
one of the major changes that create
the feeling of relaxation in warm water.!
 Results Summary cont.
•" The increase in autonomic balance did not
happen in cooler water temperatures!
•" Sympathetic activation occurred in both
cool and neutral temperatures, but not in
warm!
•" The changes noted were quite consistent
across all of the subjects tested!
 Results Summary, con’t
•" Systolic pressures remained quite constant through
all 3 immersion phases!
•" Diastolic pressures declined through the 3 phases!
•" Heart rates remained stable until climbing during the
mid-point of warm water immersion!
•" Core temperatures also rose during this latter cycle,
but only by less than 1°C on average!
 Study conclusions thus far
•" The data we have analyzed so far indicates
that in these healthy subjects there are a
number of important ANS changes that occur
during warm water immersion.!
•" There seems to be a dose response
(immersion time) relationship!
•" These changes may well have beneficial
public health implications for warm water
immersion.!
 Potential Clinical Applications
•" Depression!
•" Anxiety and panic disorders!
•" Attention Deficit Disorder!
•" Autism!
•" Cardiac Rehabilitation!
•" Diabetes, both Types I & II!
The Unique Effects of Immersion
! " Usually lowers blood pressure!
! " Reduces autonomic imbalance!
! " Strengthens inspiratory musculature!
! " Improves kidney function!
! " Increases muscle perfusion!
! " Offloads joints, and probably increases
circulation to joints!
! " Enhances cardiovascular efficiency!
The National Aquatics & Sports Medicine Institute
Research Team

Washington State University